Charting Bloopers - page 11
Found in the History and Physical section of a patient's chart who had experienced visual hallucinations while ill: "Patient vehemently denies any auditory, tactile, or old factory hallucinations." YIKES! Angela... Read More
- 7Jan 5, '03 by DIPLOMATICRN4HIREFound on a Progress Note:
55 yr m admitted with signs of chest pain. Pleasant to speak with. Family aware of status. Patient states that chest pain occured while his wife was on him having dinner.
Cardiac protocol taken.
*** found on drs orders same patient****
We had such a good time with this one..
- 4Jan 5, '03 by GotalovethekidsOne of my classmates had to correct her note after she accidentily wrote "pt ate 50% of lung"
Wouldn't that be a site to see!!!
These are wonderful but make me wonder what oddball things I've written! Oh well maybe someone will get a laugh out of me!
- 3Jan 12, '03 by JWaldronOne of my personal favorites: "Pt unconscious and complaining of leg pain". How'd he do that?
But then, I've written weird things too, especially when someone interupts me midthought an hour after my shift has ended.
- 2Jan 12, '03 by TNcanNURSEOnce I accidentally charted "pedal pulses present" and "pedal pushes palpable" in haste. The following shift another nurse who is quite notorious for copying rather than performing assessments charted the exact same thing. I found it quite amusing to see in her notes.
- 6Jan 14, '03 by RN2B2005From a radiology order form: "CXR r/o Aplat's pneumonia"
Should have read: "CXR AP/LAT r/o pneumonia"....we only figured this out after trying to look up "Aplat's pneumonia" in several radiology texts and reference manuals.
- 9Jan 15, '03 by NS_RNThe most recent funny charting transcription error I've come across was regarding Home O2.
The first one I read said "patient is on homo too"...The secomd one read"patient is a homo too". Wonder what the person who transcribed that dictation thought that was all about??LOL Esp since the rest of the dictation referred to the pts resp status!